Subcutaneous emphysema, defined as the abnormal introduction of air into subcutaneous tissues, is a rare complication of dental treatment. More common causes of this entity include trauma, head and neck surgery, and general anesthesia. We present a case of periorbital subcutaneous emphysema that clinically appeared as unilateral angioedema during a dental treatment.

REPORT OF A CASE

A 72-year-old woman with a medical history of hypertension and hypothyroidism presented to her dentist for a crown preparation of the left maxillary second molar. She denied any recent medication changes and had no history of urticarial drug reactions. She had a history of chronic periodontal disease, which left her with 4 mm of exposed root and a lack of attached gingiva.

During the dental procedure, 1 carpule of 4% articaine hydrochloride with 1:100 000 epinephrine was injected using a 30-gauge needle at the height of the mucobuccal fold of the left maxillary second molar (local infiltration). Nitrous oxide gas was also administered for 35 minutes at the patient’s request. Knitted retraction cord size No. 0 impregnated with aluminum chloride hexahydrate was placed in the gingival sulcus to retract the buccal mucosa and obtain hemostasis. No air-driven tools were used for shaping the tooth.

In preparation for the final impression, the site was then thoroughly rinsed with a combination of air and water, under equal pressure, using an air-water syringe. Within minutes, the patient developed significant soft-tissue swelling of the left lower eyelid and malar cheek. Vital signs were stable. She did not report any pain, visual problems, or difficulty breathing. The procedure was suspended. Twenty-five milligrams of diphenhydramine was administered for a suspected angioedema, and she was escorted to the emergency department (ED) for further evaluation.

Physical examination in the ED revealed prominent soft-tissue swelling of the left lower eyelid and malar cheek (Figure), and crepitus was noted on palpation. Subcutaneous emphysema was diagnosed. Her symptoms resolved over 5 days without any further complications. The patient’s dental treatment was accomplished several weeks later without incident.

Place holder to copy figure label and caption

Figure.

Clinical Images of a Patient With Periorbital Subcutaneous Emphysema

A, This image demonstrates prominent soft-tissue swelling of the left lower eyelid. B, Lateral view of the soft-tissue swelling of the left lower eyelid.

DISCUSSION

Subcutaneous emphysema is a rare complication of dental treatment that has been reported in the dental literature.1- 5 Dermatologists, emergency care providers, and primary care physicians should be aware of this complication which could be misinterpreted as angioedema as part of an anaphylactic reaction. Tooth extraction, especially the mandibular third molar, is the most commonly reported portal of entry of subcutaneous emphysema. The widespread use of air-driven handpieces has led to an increased risk of iatrogenic subcutaneous emphysema. In this case, no air-driven tools were being used immediately prior to the observation of the reaction. We suspect that the lack of attached gingiva would have allowed air to penetrate under the unattached gingiva during the placement of the retraction cord or during use of the air-water syringe used to maintain dryness and visibility.

Once air enters under the dermal layer, it may remain locally at the surgical site or continue to dissect along the fascial planes. The clinical results are local swelling, tenting of the skin, and crepitation on palpation. In extreme cases, air introduced under high pressure could pass through the masticatory space into the parapharyngeal and retropharyngeal areas, penetrating into the mediastinum. As a result, air embolism is a very rare but serious potential complication.3,4 Patients with subcutaneous emphysema usually recover spontaneously without use of any specific treatment, as was the case with our patient.1

Correspondence

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with
the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.

Indicate what change(s) you will implement in your practice, if any, based on this CME course.

Your quiz results:

The filled radio buttons indicate your responses. The preferred responses are highlighted

For CME Course:
A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes

Indicate what changes(s) you will implement in your practice, if any, based on this
CME course.

Instructions

Thank you for submitting a comment on this article. It will be reviewed by JAMA Dermatology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.

Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.

* = Required Field

Comment Author(s)* (if multiple authors, separate
names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.

This feature is provided as a courtesy. By using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to the AMA's Terms of Use. The information provided in order to email this article will not be shared, sold, traded, exchanged, or rented. Please refer to The JAMA Network's Privacy Policy for additional information.

Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.

What is this ?

Article rental gives users the ability to access the full text of an article and its supplementary content for 24 hours.
Access to the PDF is only available via article purchase.